“Insufficient Documentation” Remains #1 Reason for Improper Payments
By: Stephanie Davidson, MAC Insurance Director
Data released by the Centers for Medicare and Medicaid Services (CMS) shows that the improper payment rate for chiropractic services in Medicare is coming down, but there is still more work to be done by the profession to lower them even further. CMS measures the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Medicare’s Improper Payment Reports estimate payments made by Medicare that do not meet Medicare’s coverage, coding, and billing rules. It does not make estimates regarding fraudulent billing. For more on improper payments, click here. For the 2025 Fact Sheet, click here.
Overall Improper Payment Rates
For FY 2025, the Medicare FFS improper payment rate included claims submitted during the 12-month period from July 1, 2023, through June 30, 2024. Over that period:
- Medicare made approximately $411.05 billion in proper payments (93.45%)
- Approximately $28.83 billion in payments were made improperly (6.55%)
The Medicaid estimated improper payment rate (comprised of the past three cycles of approximately 17 state per cycle from reviews in 2023, 2024, and 2025) was 6.12%, or $37.39 billion, compared to the FY 2024 reported rate of 5.09%, or $31.10 billion. Of the FY 2025 Medicaid improper payments, 77.17% were the result of insufficient documentation, which is generally not indicative of fraud or abuse.
Chiropractic Improper Payment Rates
For chiropractic Medicare claims, however, while the improper payment rate is dropping, they remain much higher than the overall rate, with approximately 30.4% of claims (approximately $144 million) of all claims not properly paid.
Consistently, the biggest issue with chiropractic claims is insufficient documentation, followed by no documentation, medical necessity, and incorrect coding.
Improper Payments for Chiropractic (2025 vs. 2020)
| Percentage of Improper Payments by Type of Error | |||||||
|
Year |
Projected Improper Payments | Improper Payment Rate |
No Documentation |
Insufficient Documentation |
Medical Necessity |
Incorrect Coding |
% of Overall Improper Payments |
| 2025 | $144,031,007 | 30.4% | 6.0% | 89.5% | 3.0% | 1.5% | 0.5% |
| 2020 | $211,029,349 | 36.1% | 2.3% | 89.2% | 3.2% | 3.8% | 0.8% |
Medicare Documentation Resources Available
The MAC Insurance Relations Committee recommends that all chiropractors familiarize themselves with the following Medicare documentation and billing resources:
- CMS Medicare Documentation Job Aid for Chiropractic Doctors (Updated March 2022)
- MLN Matters® Number: SE1601 (Medicare Coverage for Chiropractic Services – Medical Record Documentation Requirements for Initial and Subsequent Visits) (May 7, 2019)
- MLN Matters ® Number: 1602 (Use of the AT modifier for Chiropractic Billing (New Information Along with Information in MM3449) (May 7, 2019)
- MLN Matters® Number: SE1603 (Educational Resources to Assist Chiropractors with Medicare Billing) (May 7, 2019)
- WPS Medicare Billing and Coding: Chiropractic Services (Revision Effective Date 08/28/2025)
- Medicare Benefit Policy Manual, Chapter 15, Sections 30.5 and 240 (Rev. 13774; Issued: 05-08-26)
- Medicare Claims Processing Manual, Chapter 12, Section 220 (Rev. 13316; Issued: 07-24-25)
If You Didn’t Write It Down, It Didn’t Happen.
It’s a cliché, but it’s a cliché for a reason – it’s true. If you didn’t write it down, it didn’t happen. If your records do not justify the services you bill, you’re more likely than not going to have to pay that money back.
While Medicare’s documentation requirements may seem overly burdensome, it is critical that you properly document for ALL your patients, whether Medicare, Medicaid, commercially insured, uninsured, etc. Bulletproof documentation protects both you and your patients. It promotes patient safety and quality of care, while enhancing continuity of care between different health care professionals. For your practice, strong documentation will help you justify clinical reimbursement, avoid liability, and positively impact your bottom line.
Medicare documentation is a good standard of practice for all patients, not just Medicare patients. The MAC Insurance Relations team recommends chiropractors incorporate their use in practice immediately to make your documentation the best it can possibly be.
Sources:
Centers for Medicare and Medicaid Services (CMS) Fact Sheet, Fiscal Year 2025 Improper Payments Fact Sheet, January 15, 2026
U.S. Department of Health and Human Services, 2025 Medicare Fee-for-Service Supplemental Improper Payment Data
